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Form Approved . OMB No . 2050-0039 Ari type . (Form designed for use on elite ( 12-per. , , Typewriter.) i `Jr UNIFORM HAZARDOUS ID NResponse Phone 4 Manitest Tracking Number I Generator Numb er 2 , Page 1 of 3. Emergency Respo r LE WASTE MANIFEST ; ,e , . ' F 5. Genaratcr's Name and Mailing Address Generator's Site Address it different than mailing address) Generator's Phone: PU .S . EPA ID Number 6 . Transporter 1 Company Name U .S. EPA ID Number 7 , Transporter 2 Company Name U .S . EPA. ID Number 8 . Designated Facility Name and Site Address _ Facility s Phone : 10. Containers 11 , Total 12, Unit 13 , Waste Codes ga 9b. U .S . DOT Description ( including Proper Shipping Name, Hazard Class, ID Number, Quantity Wt. Vol . HNI and Packing Group (if any)) No. Type dL O (� 1 W t,l,.t - 3 . SEP 0 6 I010 . ._. . .__ � A a ,1 , " 1 � , Special Har „ g � stnx":Ions and Adoltioral Information r . ; 5. GENERATDR'SIQFFEROR' S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged , marked and labeledlplacarded . and are In all respects in proper condition for transport according to applicable nternaticpal and national governmental regulations . If export shipment and I am the Primary Exporter, I cert iy that the contents of this consignment conform to the terms of the attached EPA Acknowledgme t of Consent. I certify that the waste minimization statement identified in 40 CFR 262 .27(a ) (if I am a large quantity generator) or (b) (if I' am a small quantity generator) is true . ont ay ear cnatura Generato.s;Offerors PrintedrTyped Name ' 1fi. intern�iional Ship ,tints ❑ Exportfrom U .S. r Po of entry/exit: Imoort to U S . Date leaving U .S .. Z Transporter signature (for exports only): � 17 . Transporter Acknowledgment of Receipt of Materials _ Month Day Year w Signa`ure Transporter 1 PrintedrTyped Name r �' " Y I " Si nature I Month I Ga Yea z Transporter 2 P•inted,,Tvped Name g '- Q tx 18 Discrepancy ' 8a Discrepancy Indication SpaceEl ❑ Residue ❑ Partial Rejection ❑ Full Rejection ❑ Quantity Type Manifest Reference Number: U S . EPA ID Number 18b . Alternate Facility (or Generator) v Facility's Phone: Menih Day Ye UWj 18c. Signature of Alternate Facility (or Generator) Q z 19. Hazardous Waste Report Ivlanagement Method Codes (i .e., codes for hazardous waste treatment, disposal , and recycling systems) 4 . 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Month Day YE Signature ;' p Print edTyped Name g r t y . xir ITY TO G S1 =acil . IE . EPA Form 8700-22 (Rev. 3-05 ) Previous editions are obsolete . _ . . —